Panel #3 from the 2013 Regional Oncology Conference.

1. Panel 3:
Creating a Responsive Health
Care System for Patients with
Advanced Rectal Cancer
Panelists:
Sherri Baker NCFW BSW RSW
Silvana Spadafora MD FRCP(C)
Patrick Critchley MD CCFP FCFP

2. Mr. TW: Case History 3
• Mr. TW completes therapy and is followed
appropriately over the next 10 years
• He presents with liver metastases and is
referred to the cancer centre
• His case is assessed for “HPB” rounds. He
has pre-op chemo and metastasectomy
• Over some time his disease slowly
progresses. He enters the palliative phase

3. The Role of the
Aboriginal Patient Navigator
Sherri Baker NCFW BSW RSW
Aboriginal Patient Navigator
Northeast Cancer Centre, HSN

4. Role of Aboriginal Navigator
• Support at clinical visits
– Attending or speaking with attending physicians regarding patient
status.
• Communication with health care providers & make appropriate
referrals to other services
– i.e. hospice, health services in the patients community.
• Language and cultural translation
– Accessing services through the medicine lodge
• Address the cultural and spiritual needs / travel / finance/ caregiver
and family needs.
– Assisting with accessing any NIHB, ODSP, elders or other community
services both in Sudbury and their home community.
• Other psychosocial needs
– Counselling or supportive services

5. Accessing services
All people who self identify as First Nations, Métis & Inuit
are in need of supportive services.
Referral to services can come from an Internal source,
Self and or a community referral.
Patients must have a diagnosis of cancer and are
ambulatory patients.

6. Management of CRC
Liver Metastases
Silvana Spadafora MD FRCP(C)
Medical Director Algoma District Cancer Program
Regional Clinical and Quality Co-Lead for Systemic
Treatment

7. Role of Liver Metastasectomy
CCO’s Program in Evidence Based Care:
• Liver resection…offers the possibility of cure in
stage IV disease limited to the liver.
• Patients who have complete resection of the
liver metastases have a 5 yr. survival rate of ~
45% and a 10 yr. survival rate of 25%
• Patient selection is very important and done
through Multidisciplinary Case Conferences
CCO PEBC Evidence-based Series 17-7: The role of liver resection in colorectal cancer metastases June 2012

9. The pathway for a real patient
2008:
• 77 yr. male with rectal bleeding → rectal
lesion → staging negative, CEA 1.6.
• Neoadjuvant chemo-radiotherapy →
surgery → margins not identified, N2
• 6 months oral adjuvant → staging
negative, CEA 0.8.
• Appropriate CEA & imaging follow-up

10. The pathway for a real patient
2010
• CEA 10; R lobe liver metastases on CT
• Reviewed by Toronto Hepatobiliary Team
• Metastasectomy performed in Toronto
• No chemotherapy required
• Post-op CEA 1.0
2013
• Age 83 and CEA remains 0.8-1.2

11. Clinical Tools and
Guidelines for Primary Care
Patrick Critchley MD CCFP FCFP
Regional Primary Care Lead: Northern Districts
Northeast Cancer Centre, HSN

12. Objectives
• ESAS - Edmonton Symptom Assessment
Scale
• PPS - Palliative Performance Scale
• Cancer Care Ontario Symptom
Management Guidelines

13. Primary Care
Ideal position to provide and coordinate
palliative care:
– Long-established relationships with our
patients
– Use to dealing with co-morbidity and
uncertainty
– Trained to treat patients holistically

14. Health Care Team
• Expanding number of members
• Changing and expanding roles
• Working in multiple settings
• Communication and use of a common
language are key to success

15. Would you be surprised if your patient
were to die in the next 6-12 months?
– General Indicators of decline and increasing
needs
• change in performance status, co-morbidity,
advanced disease, decreasing response to
treatment, weight loss, etc.
– Specific Clinical Indicators
• Cancer - may see rapid or predictable decline
• Organ failure - erratic decline
• Frailty/dementia - gradual decline

16. If the answer is “no I would not
be surprised”….
– consider palliative care approach
– involve appropriate resource/team members
– initiate proactive management (less crisis
management)
– plan according to patient’s preferences
– assess patient and family needs ongoing and
regular basis
– utilize tools for assessment and symptom
management

17. Tools
• Edmonton Symptom Assessment Scale
(ESAS)
– Validated multidimensional symptom
assessment tool
– Self-rating using scale of 0 - 10 for severity of
9 common symptoms and one additional
symptom described by the patient
– Measures how the patient is feeling at the
time of completing the scale

18. ESAS - uses
• Measure and document common
symptoms in EOL
• Provide a good overview of symptoms in
individual patients
• Highly effective in the recognition of
unreported symptoms particularly when
combined with further interviewing to
obtain the details of the positive responses

20. ESAS Benefits
• Common language between health care
providers
• Efficiency
• Monitoring benefits of treatment plan

21. ESAS utilization in Primary Care
• TPC Demonstration project 2004-2006
– Visiting home RNs collected ESAS at each
visit
– Sent in to CCAC office
– Entered into patient chart
– Team rounds - ESAS graphs for each patient
was presented and reviewed at regular team
meeting
– Management and education plan was
formulated

22. ESAS utilization in Primary Care
• Family Physician office
• Patient completes the ESAS and responses are
entered into a stamp by secretary or RN
• Practice Solutions
• Can graph the scale
• Can track medications on the scale
• Facilitates a efficiency in the office assessment
and treatment plan

23. Tools
• Palliative Performance Scale (PPS)
– Originally developed for hospice patients
– Based on Karnofsky’s Performance Scale
– Clinician rated on 0% - 100% scale
– 0 - deceased
– 100- fully functional

24. PPS
• 70-100% - stable
• 40-60% - transitional
• 0-30% - end of life

26. PPS - uses
• Useful in determining prognosis in
advanced cancer

28. PPS - Benefits
• Common language
• Prognosis:
– prepare patient, family, team
– facilitate discussions regarding care wishes
and planning including - Will, POA, funeral
– advocate for additional services (CCAC)

29. So now what?
• I’ve had the patient complete the ESAS now what?

30. Care Care Ontario Website
• CCO Toolbox Tab
– Palliative Care Tools
• PPS - tool and description (PDF)
• Collaborative care plans linked to PPS score
(PDF)
– App Library
• Symptom Management Guidelines (link to App
store)
• Drug Formulary (link to App store)

31. Care Care Ontario Website
• CCO Toolbox Tab
– Symptom Management Tools
• ESAS - description (PDF)
• ESAS Tool - (languages)
– Symptom Management Guides
• 10 symptoms
• Algorithms, Pocket Guides, Guide-to-practice
(PDF, printable, downloadable), Videos

35. CCO - Symptom Management
Guide App
• Pain, Dyspnea, Depression, Anxiety,
Nausea and Vomiting, Delirium
• App is an algorithm
– Based on severity of patient’s identified
symptom (ESAS)
– Guide assessment
– Assist with care planning including both nonpharmacological and pharmacological
– DOES NOT REQUIRE WIFI TO FUNCTION

37. North East Oncology News
www.hsnsudbury.ca under Northeast Cancer Centre, Professional Resources and Networks, Primary Care Resources

38. In conclusion
• Consider:
– asking the question “would I be surprised?”
– utilizing the PPS and ESAS in your
management plan for palliative patients
– Exploring CCO Website for these tools and
symptom management guidelines - proactive
not during a crisis

39. Download your CCO-SMG
App today!
To Download, Search:
App Library CCO